Wednesday, March 09, 2005

JAMA article:Computerized doctor order system shown to facilitate errors

The March 9, 2005 issue of JAMA published an article with evidence that CPOE (Computerized physician order entry) systems may actually have the effect of increasing mediations errors. The authors investigated the effects of a particular system at one teaching hospital. Ordering medication in a hospital is a complex, multi-faceted process and reliance on a system that oversimplifies and does not capture important subtleties and particulars is likely to cause more harm than good.The authors describe numerous, potentially harmful, glitches in the system (they describe 22 situations in which the system increased the likelihood of error and instances of house staff and nurses having to "work around" the system).An editorial has an excellent discussion on the conceptual disconnect between clinical work and CPOE and decision support systems. It suggests that what clinicians really do is "sense making"-i.e. making sense of the clinical picture rather than simplified, conceptualized "decision making".It is not easy to devise a computer system to "make sense" of complex,often ambiguous clinical elements if for no other reason than it is hard to make sense of any given particulars let alone make an abstract meta-plan to solve clinical problems generally.One aspect not mentioned is the tendency of people to abdicate their responsibility for the activity to the computer system. For example, if they believe a program is monitoring drug dose, drug interactions, drug appropriateness etc, there is a tendency to ignore and not take control of those considerations.The editorial's subtitle is "Waiting for Godot". If we believe that all of the problems of medicine can be managed by computer programs, we will be waiting for something that never arrives like the tramps in Beckett's play.

2 comments:

I believe the term of art is moral hazard. Antibiotics make us less concerned about infections; immunizations make us less careful about spreading disease; drug cocktails make us less careful about using condoms. That all may be true. It's still no reason stop making progress in alleviating human disease and pain.

Information technology should be the servant of the physician not his master. Prudent design and the active participation of medical professional in developing such tools would help.

System Design and Error Trapping of one particular system is the problem here.

Bad Program does not equal Bad Idea.

The problem is that human error experts need to become knowledgable in and an accepted part of medical systems planning, implementation and surveillance - computerized and otherwized - before we can expect significant error reduction.